The Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of Regulation 12 (Safe Care and Treatment) due to the safety concerns identified during the assessment

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff did not always identify or respond consistently to safety concerns. For example, during the inspection we observed a person stuck between chairs in the lounge, but only 1 staff member was present, and they were supporting another person to eat, and unable to assist immediately. Staff also did not always identify when people needed repositioning, as 1 person had slipped forward in their chair and required prompting to ensure they were safe. These examples showed that staff did not always recognise or act on safety risks in the moment, and learning was not consistently embedded in day‑to‑day practice.

The management team were responsive and took actions when matters were brought to their attention. For example, our immediate feedback on safety on day 1. But the broken door lock giving access to the unsafe loft area had been known about for days before our inspection and no immediate action had been taken to make it safe.

We received feedback from 2 professionals regarding how the management team responded to concerns. One professional told us they had raised a safety issue with the registered manager to protect the person they were supporting, but they were not confident that appropriate action would be taken. Another professional reported that despite requesting incident records to support their monitoring and oversight of the service, these had not been provided.

Accidents and incidents were monitored by the management team. Statistical information was available, but further consideration was needed around preventative work and how this was embedded in the service.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People were encouraged to visit The Lodge to see if the service was suitable for them. Assessments were completed or obtained. These were more detailed and robust in the main house, than those seen in The Coach House. For example, in the main house detailed initial assessments were carried out. These assessments looked at what support people needed, which helped create care plans and risk assessments to ensure information was appropriately made available for those supporting people’s needs. In The Coach House, initial assessments were completed but care plans and risk assessments were not robust enough to offer clear guidance to those supporting people using that service or reduce risk of potential harm.

The service was providing care at The Coach House but it was not clear which individuals could or could not be accommodated safely and how their specific needs could be met, this was despite the service being operational for some time. The therapeutic element of what would be offered to people at The Coach House had yet to be developed. Potential risks were not always considered or thought through, therefore this system was not as safe as it could be.

The provider had safeguarding policies in place. Staff had been trained in safeguarding and there was a notice in the service with information displayed about safeguarding practice and contacts. However, we were not assured the training was effective as staff were not always able to tell us about the procedures relating to safeguarding and how to contact the local authority safeguarding team.

The local authority was not informed of an incident that resulted in the death of a person using the service. They had not received information from the provider regarding incidents despite requesting these as part of their contracts monitoring role. This meant important safeguarding oversight and external monitoring were delayed, increasing the risk that serious concerns were not identified or addressed promptly.

Staff confirmed they had received training in Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). DoLS referrals had been made as required, however, we received feedback from a relative regarding the restrictions in place for their family member, which were ongoing prior to the DoLS being approved.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s care records contained information about the support they needed to manage risks, such as guidance for moving and handling or eating and drinking. However, some records lacked sufficient detail to fully ensure people’s safety. For example, the care records for people with diabetes needed more specific information, and although a staff member told us that one person had a moisture lesion, the wound care plan in their file had not been completed. A visiting health professional confirmed they had been informed by staff and were monitoring the issue.

Staff told us they had received online training in supporting people with distressed behaviours. However, we found that there where people had mental health support needs, their care records did not give enough detail on how these specific risks were to be reduced to keep them safe. A visiting professional told us they had offered further training sessions to the staff team to support them, and plans were being made by the service to provide this.

Staff received training in moving and handling, and a staff member told us there were systems in place to check their competency.

People shared examples with us of times when the staff approach was not considerate and respectful making them feel vulnerable. For example, a person said that new staff were, “Not competent,” and had entered their room without knocking. Another person said they had been startled by a staff member entering their room suddenly.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During our inspection we found environmental risks which had not been addressed, placing people at risk of harm. In a person’s room we observed their wardrobe was not secured to the wall, in addition, there was a bag on top of the wardrobe, this was a risk of both the bag and the wardrobe falling on to the person and injuring them. In another room the radiator was not covered with exposed pipes which was a risk if people touched them whilst hot. We found windows did not always have restrictors, fire doors were wedged open and there was access to loft areas and steep staircases. We were concerned about the safety of people using the service and asked the provider for an action plan to tell us how the immediate risks would be mitigated. The provider told us actions had been taken, some of which had been taken immediately following out first visit. However, we were concerned the systems in place were not robust enough to identify, assess and address potential risks to people.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The provider had a good recruitment process in place. The recruitment files we reviewed showed staff had completed application forms, appropriate photo identification, right to work in the UK and Disclosure and Baring Services (DBS) checks in place. Staff had provided full employment histories and work references to ensure recruitment was safe. Staff received an induction at the beginning of their employment, that was relevant to their role to keep people safe. Staff told us they were happy working with the service, and they felt supported by the registered manager. Healthcare professionals we spoke to shared positive feedback about staff at the service and found them supportive and committed to providing good care.

We were not assured training was always effective as staff were not always proactive in recognising risks to people and taking action to reduce risks and were not all clear on their responsibilities relating to safeguarding. People listed some staff who they felt were skilled in providing their care. A person referred to the staff as, “Brilliant.” However, a person told us they felt a newer staff member may require training because they were sharp when speaking with them and did not knock their bedroom door before entering which had made them jump. Another person told us some staff were, “Very quiet,” and did not talk with them. Staff told us they felt there were enough of them to meet people’s needs, this was confirmed by people and relatives who we spoke with. However, a visiting professional told us, “Not enough staff to transfer, and support in areas that are not always appropriate taking into account privacy and dignity, staff always seem rushed off their feet.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service was not clean and hygienic throughout. We noted malodours in the service, which did not demonstrate effective cleaning. Equipment was rusty, including a commode, which did not support effective cleaning practices. The sealant between the wall and floor in the bathroom was damaged and a build-up of dirt was present. This put people at risk of bacterial growth and potential for infection. Some armchairs had damaged upholstery making it difficult to clean and this put people at risk of their skin being damaged and bacteria growth.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider had a medicine policy in place informing staff how to ensure medicines were delivered and managed safely. Medicines were locked in a secure cupboard, and keys were with staff allocated to administer medicines. The fridge used for medicines was cleaned and used for medicines only. The temperature was monitored and recorded appropriately. Medicines given was recorded on an electronic system which worked to reduce the risk of error.

Staff told us their competency was checked before they were supporting people with their medicines, and this was refreshed annually.

Where people required medicines to be administered as required (PRN), there were protocols in place, however, these were not detailed enough to reduce the risks of inappropriate administration, for example, how a person’s distress reactions showed and at what point the medicines were to be considered.